Humana Healthy Horizons in Florida Preauthorization and Notification List
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Defines preauthorization and notification requirements for a range of services for Humana Healthy Horizons Medicaid members in Florida and explains who manages specific service categories and how providers should request preauthorization or submit notifications.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization or Notification
Prior authorization and notification criteria
Services listed below require either prior authorization or notification as specified. Some behavioral health and DME/homecare categories are managed regionally by third-party vendors; certain high-complexity services require specialized review.
Inpatient admissions
- Transplants and planned inpatient medical and surgical admissions require prior authorization.
- Partial hospitalization requires notification.
- Behavioral health inpatient/residential/partial hospitalization management differs by region: Access Behavioral Health manages north Florida (region A); Carelon Behavioral Health manages central and south Florida (regions B, C and E).
Advanced imaging (CT and MRI)
Behavioral health services
- Outpatient behavioral health, IOP and partial hospitalization are managed by Carelon in regions except A; IOP and partial hospitalization are notification required; a licensed clinician is available 24 hours/day with business‑hours contact provided.
Durable medical equipment and homecare
- One Homecare Solutions manages south Florida regions G, H and I for specified DME; Humana manages other regions.
Molecular diagnostic and genetic testing
Outpatient services
- Routine maternity care is notification only per the PAL.
Surgery
- Certain surgical procedures (examples listed in the PAL such as specified blepharoplasty, select breast procedures, lipectomy, obesity surgery) require prior authorization per the PAL.
Cellular, transplant and VADs
- CAR‑T, cellular/genetic/tissue therapies, transplants, and ventricular assist devices require prior authorization and specialized review by the Humana National Transplant Network; submissions must be made via Availity.
Specialty drugs
- Prior authorization is required for specialty drugs listed when delivered in a provider’s office, clinic, outpatient or home setting; use the Humana professionally administered drugs prior authorization forms/webpage to request authorization or provide notification.
Code Lists and Coverage Status
| A9276-A9279 | Continuous glucose monitoring devices and supplies |
| Q4101-Q4252 | Selected Q-codes for skin and tissue substitutes |
| 33975 | Ventricular assist device procedure code |
| 33976 | Ventricular assist device procedure code |
| 33977 | Ventricular assist device procedure code |
| 33978 | Ventricular assist device procedure code |
| 33979 | Ventricular assist device procedure code |
| 33981 | Ventricular assist device procedure code |
| 33982 | Ventricular assist device procedure code |
| 33983 | Ventricular assist device procedure code |
How Providers Request Authorization and Required Notifications
How to request preauthorization
Preauthorization requests may be initiated online at Availity.com (registration required), by calling 866-856-8974 Monday–Friday, 7 a.m.–7 p.m. ET, or by faxing clinical information to 813-321-7220.
- Availity.com — registration required
- Phone — 866-856-8974 (Mon–Fri, 7 a.m.–7 p.m., Eastern time)
- Fax — 813-321-7220
When to notify vs. request prior authorization
Notification is required for certain services to inform Humana of the intent to provide care; Humana does not issue an approval or denial when a notification is submitted. Urgent/emergent services do not require prior authorization or notification.
- Notification = informing Humana of intent to provide an item or service; no approval/denial is issued
- Urgent/emergent services are exempt from referral, prior authorization and notification requirements
Consequences of not obtaining required authorization/notification
Failure to obtain required prior authorization or notification may subject the service to retrospective medical necessity review and could result in financial penalties for the practice and reduced patient benefits per the provider contract and patient evidence of coverage.
- Potential financial penalties for the practice
- Reduced patient benefits based on contract and evidence of coverage
- Services provided without prior authorization/notification may be retrospectively reviewed for medical necessity
Specialized review via Humana National Transplant Network
Prior authorization requests for transplants, CAR T‑cell (cellular) therapies and ventricular assist devices (VADs) will be reviewed by the Humana National Transplant Network and must be submitted via Availity.
- Humana National Transplant Network performs specialized review for transplant, CAR T‑cell and VAD requests
- Submit these prior authorization requests through Availity
Prior authorization for professionally administered specialty drugs
Prior authorization is required for specialty drugs listed when delivered in a provider's office, clinic, outpatient or home setting; Humana's prior authorization forms for professionally administered drugs are available on Humana's professionally administered drugs webpage.
- Requirement applies to specialty drugs administered in office, clinic, outpatient or home settings
- Use the fax forms available on Humana's prior authorization for professionally administered drugs webpage to request authorization or provide notification
Key Terms
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